Outcome and Prognosis
The outcome and prognosis of acute nerve injury varies widely among the different types of injuries and the type and timing of therapy. Patient compliance and motivation for recovery also can have an important impact on the success of recovery.9 In traumatic hip dislocations and fracture dislocations, at least partial return of nerve function can be expected in approximately 60-70% of patients.1 The extent of injury to neural tissue, contamination of the wound, and the age and medical status of the injured patient are important factors influencing the outcome and prognosis of recovery.3 Surgical delays in excess of 5 months dramatically decrease the rate of functional return.15 Therefore, schedule surgical repairs within 3 months following the injury.15
Neurapraxic injuries usually are reversible, and patients recover within days to weeks.4,6 In axonotmesis, although axons regenerate, functional recovery depends on the associated injuries, the amount of healthy proximal axon remaining after injury, and the age of the patient.6
In addition, recovery usually is complete unless the injury is so proximal that atrophy of the motor endplate or sensory receptor occurs before the axon can grow back to these organs.3,5 A loss of cross-sectional area without any loss in muscle fiber count begins within 1 week of denervation.9 Recovery from axonotmetic injuries usually occurs over months.4 In neurotmesis, regeneration occurs but function rarely returns to normal.6 Intraoperative care with proper axial orientation of fascicles, proper coaptation, suture material, hemostasis, and suture line tension leads to better outcomes.6 Tension of the suture line and inadequate preparation of the nerve stumps are 2 leading causes of regenerative failure across the suture site, resulting in poor recovery of nerve function.4
Spontaneous recovery (which occurs in two thirds of cases) may occur as late as 11 months after a gunshot wound. However, recovery after shotgun wounds is lower, with a 45% incidence rate of recovery.3 Neural injuries associated with fractures have a greater than 80% incidence rate of spontaneous resolution. Recovery is less common with neural injuries secondary to dislocations.3 Lesions resulting from shoulder dislocations recover within 12-45 weeks.10 Prior radiation therapy impairs cell division. This may affect Schwann cell division after nerve injury.16
Future and Controversies
In future research, decreasing the variability of injury and of functional recovery measurements will hopefully increase the sensitivity of the system to evaluate neuropathology and experimental interventions.17
Developing the ideal nerve injury model that can simulate acute hypoxic nerve injuries and be evaluated by functional models for regeneration is important to obtaining a greater understanding of neuropathophysiology and potential therapeutic interventions.17
Experimental surgical techniques are being explored. In one repair technique, the injured nerves are frozen at the time of sectioning and repair and a protective solution is used to bathe the cut ends of the nerve during repair. Synthetic tubules have been used to encase the sectioned end of an injured nerve to allow regrowth. This technique seems to offer comparable or better results than suturing the nerve ends.3
Metabolic manipulations using pulsating electric fields across a nerve repair and administration of various biochemicals, including thyroid and adrenal hormones, anti-inflammatory agents, and other agents known to influence neurite growth in vitro, are being explored in experimental studies of nerve injury.3 Clinical trials using trophic molecules to enhance axonal regeneration over time include insulinlike growth factors 1 and 2, NGF, BDNF, and neurotrophin 3 and 4/5.4 Vascularized nerves can be useful to repair nerves longer than 8 cm and grafts placed in poor vascular beds that are heavily scarred.19
The use of MRI before surgery may be standardized in the future. Having a picture of the nerve anatomy before performing the surgery is valuable tool.1
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Caitlin Gonzalo, TO, to the development and writing of this article.
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Further Reading
Keywords
acute nerve injury, neurosurgery, nerve injury, nerve repair, neurapraxia, axonotmesis, neurotmesis, fractures, fracture-dislocations, mechanical injury, crush injury, percussion injury, laceration injury, peripheral nerve damage, nerve damage, blunt trauma, penetrating trauma, stretch injury, high-velocity trauma
